Anteroinferior versus superior plating of clavicular fractures

Functional outcomes and complications of plate fixation for midshaft clavicle fractures by type and location: a systematic review and meta-analysis

Background

Various plate types are used in the surgical treatment of displaced midshaft clavicle fractures. These plates can be positioned in different locations on the clavicle, although no studies to date have elucidated optimal plate type and location of fixation. This systematic review compares the functional outcomes and complications in the management of displaced midshaft clavicle fractures using plate fixation by stratifying by both plate type and location.

Methods

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted to identify all papers reporting functional outcomes, union rates, and/or complications using plates for the management of midshaft clavicle fractures. Multiple databases and trial registries were searched from inception until March 2022. A meta-analysis was conducted for functional outcomes and type of complication, stratified by plate type (locking, compression, or reconstruction) and location (superior or anteroinferior). Pooled estimates of functional outcome scores and incidence of complications were calculated using a random effects model. Risk of bias and quality were assessed using the risk of bias version 2 and ROBINS-I (Risk Of Bias In Non-randomised Studies - of Interventions) tools. The confidence in estimates were rated and described according to the recommendations of the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) working group.

Results

Forty-five studies were included in the systematic review and 43 were included in the meta-analysis. Depending on plate type and location, pooled Constant-Murley Scores ranged from 89.23 to 93.48 at 12 months. Nonunion rates were 3% (95% confidence interval [CI] 1-6) for superior locking plates (GRADE Low). Rates of any complication (nonunion, hardware failure, hardware irritation, wound dehiscence, keloid, superficial infection, deep infection, delayed union, malunion, and/or persistent pain) by plate type and location ranged from 3% to 17% (GRADE Very Low to Moderate). Superior compression plates had the highest incidence of any complications (17% [95% CI 5-44], GRADE Very Low), while anterior inferior compression plates had the lowest incidence of any complication (3% [95% CI 0-15], GRADE Very Low). Hardware irritation was the most reported individual complication for superior locking plates and superior compression plates, 11% (95% CI 7-17, GRADE Low) and 11% (95% CI 3-33, GRADE Very Low), respectively.

Conclusion

Although most studies were of low quality, studies reporting functional outcomes generally showed good functional results and similar incidence of any complication regardless of plate type and location. There is no evidence of a plate and location combination to optimize patient functional outcomes or complications. We were unable to reliably evaluate union rates or individual complications for most plate types stratified by location.

Comparable results of superior vs antero-inferior plating for the treatment of displaced midshaft clavicle fractures. A comparative study

BACKGROUND

Clavicle fractures represent up to 10 % of all fractures, affecting mainly a young population. Open reduction and internal plate fixation provide good results, but evidence on the best plate positioning is still unclear. Aim of this retrospective study was to compare superior and antero-inferior plating positioning in the surgical treatment of displaced midshaft clavicle fractures.

MATERIALS AND METHODS

104 patients aged > 18 years, treated surgically with plate fixation (51 superior, 53 antero-inferior) for a midshaft clavicle fracture from January 2010 to April 2021 were included. At the time of the visit, mean follow-up time was 6.6 ± 2.6 years. Shoulder function was evaluated with the use of Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Return to sport, aesthetic satisfaction, operative time, radiological outcomes, rate of implant removal, and overall patient satisfaction were documented as well.

RESULTS

Mean CMS was 94.1 ± 10.0 points in the superior plating group and 93.4 ± 11.6 points in the antero-inferior plating group. DASH score: 4.6 ± 11.0 superior, 5.1 ± 10.5 antero-inferior. Return to sport: 8.2 ± 2.9 superior, 8.2 ± 3.0 antero-inferior. Aesthetic satisfaction: 8.9 ± 1.6 superior, 8.8 ± 2.1 antero-inferior. Overall satisfaction: 9.1 ± 1.5 superior, 8.9 ± 1.7 antero-inferior. The comparison between groups showed no statistically significant differences (p = n.s.) for all outcome measures. Operative time: 101.6 ± 27.3 min superior, 113.0 ± 31.6 min antero-inferior (p = 0.05). Radiological follow-up documented one non-union and one mal-union in the antero-inferior plating group. Overall, 63 patients underwent plate removal: 58.8 % in the superior plating group and 62.3 % in the antero-inferior plating group (p = n.s.). Main reason for plate removal was pain/discomfort.

CONCLUSIONS

Both superior and antero-inferior plating provided excellent clinical, functional, and radiological results for the treatment of displaced midshaft clavicle fractures, without significant differences between groups. The superior plating group showed a statistically shorter operative time. High rate of re-interventions with implant removal was documented in both groups.

LEVEL OF EVIDENCE

III.

Lateral clavicle fracture-plating options and considerations

Clavicle fractures are among the most prevalent types of fractures with numerous treatment strategies that have evolved over time. In the realm of lateral-third clavicle fracture management, several surgical methods are available, with plate and screw constructs being one of the most frequently employed options. Within this construct, numerous choices exist for fixing the fracture. This editorial provides an overview of the common plate options utilized in the management of distal third clavicle fractures underscoring the critical considerations and approaches that guide clinicians in selecting the most appropriate fixation techniques, considering the complex landscape of clavicle fractures and their challenging management.

Elective implant removal in the upper extremity: only symptomatic patients benefit

PURPOSE

Elective implant removal (IR) in the upper extremity remains controversial. Implants in the olecranon and clavicle are commonly removed for prominence, unlike in the distal radius. Patient-reported symptomatic cannot be verified, and nonspecific discomfort remains unquantified. In this study, indications and outcomes of IR at the clavicle, olecranon and distal radius were evaluated, with a focus on postoperative patient satisfaction.

MATERIALS AND METHODS

In this retrospective, single-center cohort study, patients, who received elective IR of the clavicle, olecranon and distal radius were included. Patients were followed up at least six weeks after IR. Outcomes included patient satisfaction, symptom resolution, and complications.

RESULTS

One hundred and eighty-nine patients were included. Unspecific symptoms of discomfort were the most prevalent indication for IR (48.7%), followed by pain (29.6%) and objective limited range of motion (ROM) (7%). Pain and limited ROM combined was observed in 13.8%. Subjective benefit following IR was described in 54%. Patients with limited ROM (OR 4.7, p < 0.001) or pain (OR 4.1, p < 0.001) were more likely to experience alleviation of complaints. Patients with unspecific symptoms of discomfort, often did not report improvement. Major complications occurred in 2%. Refractures were detected at the clavicle (3.7%) and at the olecranon (2.5%). Minor complication rate was 5%.

CONCLUSION

IR is a safe procedure in the upper extremity. Indications based on unspecific symptoms of discomfort have a significant lower rate of patient satisfaction postoperatively. Elective IR should be considered cautiously, if it is driven primarily by unspecific symptoms of discomfort. Patient education is relevant to prevent dissatisfying outcome.

Does plate position influence the outcome in midshaft clavicular fractures? A multicenter analysis

PURPOSE

To date, it remains unclear whether superior or anterior plating is the best option for treating midshaft clavicular fractures. The aim of this study was to compare both techniques with regard to the incidence of implant removal due to implant irritation, risk of complications, time to union, and function.

METHODS

In this retrospective cohort study, all midshaft clavicular fractures treated operatively between 2017 and 2020 in two hospitals in Switzerland were analyzed. The participating hospitals differed with regard to their standard practice; one offered superior plating only, while the other predominantly employed an anterior plate. The primary outcome was the incidence of implant removal for irritation. Secondary outcomes were time to union, complications, re-interventions, and range of motion during the follow-up period of at least 6 months.

RESULTS

In total, 168 patients were included in the study of which 81 (48%) received anterior plating and 87 (52%) superior plating. The overall mean age was 45 years (SD 16). There was no significant difference between anterior and superior plating with regard to implant removal (58.5% versus 57.1%, p = 0.887), infection (5.7% versus 1.8%, p = 0.071), and time to union (median 48 weeks versus 52 weeks, p = 0.643). Data on range of motion were available in 71 patients. There was no significant difference in anteflexion (median 180 degrees anterior versus 180 degrees superior) and abduction (median 180 degrees anterior versus 180 degrees superior) between the two groups.

CONCLUSION

This retrospective cohort study did not find sufficient evidence to recommend one implant position over the other for midshaft clavicular fractures with regard to removal due to irritation. Time to union was similar and Infections were equally rare in both groups. Notably, a considerable number of patients in both groups had their implants removed due to irritation. Larger prospective studies are needed to determine how much plate position contributes to the occurrence of irritation and whether other patient or implant-related factors might play a role. Until this is clarified, implant position should be based on surgeons preference and experience.

Distal clavicle fractures treated by anteroinferior plating with a single screw: Two case reports

BACKGROUND

For the treatment of distal clavicle fractures, each treatment method has its own advantages and disadvantages, and there is no optimal surgical solution.

CASE SUMMARY

Based on this, we report 2 cases of distal clavicle fractures treated utilizing an anterior inferior plate with a single screw placed in the distal, in anticipation of providing a better surgical approach to distal clavicle fracture treatment. Two patients were admitted to the hospital after trauma with a diagnosis of distal clavicle fracture, and were admitted to the hospital for internal fixation of clavicle fracture by incision and reduction, with good postoperative functional recovery.

CONCLUSION

With solid postoperative fixation and satisfactory prognostic functional recovery, this technique has been shown to be simple, easy to perform and effective.

Dual- Versus Single-Plate Fixation of Clavicle Fractures: Understanding the Rationale Behind both Approaches

Clavicle fractures are a common injury resulting from a high-energy force, such as a fall onto the shoulder, motor vehicle accident, or sporting activity. Although some clavicle fractures may be treated nonoperatively, operative treatment results in higher union rates and faster return to activity. Here we discuss the operative treatment options for plating of clavicle fractures; specifically, a single plate placed either superiorly or anteriorly or two plates placed orthogonally. Because both techniques provide adequate stability, fracture and patient characteristics should guide the surgical decision making regarding single versus dual plating of clavicle fractures.

Low rate of secondary surgery and implant removal following superior, precontoured plating of midshaft clavicle fractures

Background

Surgical fixation of midshaft clavicle fractures with a single 3.5 mm superior clavicular plate has been associated with a high rate of hardware removal due to symptomatic hardware. Because of this, dual-plating techniques with lower-profile implants have been proposed. However, dual-plating systems have disadvantages, including increased cost and increased surgical morbidity. The aim of this study was to define the rate of symptomatic hardware removal for all midshaft clavicle fractures.

Methods

We retrospectively reviewed information on all patients from 2014 to 2018 at a single level 1 trauma institution with surgeries performed by two fellowship-trained orthopedic trauma surgeons. Documented removal of hardware and the reason for removal were recorded. We then contacted all patients at their listed telephone number to confirm the hardware was still in place and to administer patient outcome questionnaires. If patients did not answer, attempts were made to contact them multiple times on multiple days. Those who were not reached but had documented hardware removal were included in the total number of patients with hardware removal.

Results

The search revealed 158 patients, of whom 89 (61.8%) were included in the study. Average follow up was 4.09 years (range 2.02-6.50 years). Five patients (5.56%) underwent hardware removal. Removal was for symptomatic or irritating hardware in two of these patients (2.22%). Average abbreviated Disability of Arm, Shoulder, and Hand score was 6.27, and average American Society of Shoulder and Elbow Surgeons shoulder score was 93.6.

Conclusion

In our series, the rate of symptomatic hardware removal was 2.22%, well below reported removal rates. Hardware removal rates for prominent symptomatic superior clavicular plates may be significantly lower than previously reported, and these fractures may be adequately treated with a single, superior plate.

Anteroinferior plating is an independent factor for decreasing symptomatic implant removal rates after plate fixation for midshaft clavicle fractures

Objectives

The factors that significantly influence the symptomatic implant removal rates after plate fixation for midshaft clavicle fractures remain controversial. The purpose of this study was to compare the symptomatic implant removal rates between 2 different types of plating technique and to evaluate independently associated factors.

Design

Retrospective cohort study.

Setting

Acute care center.

Patients/Participants

A total of 71 patients 16 years or older who were diagnosed with displaced midshaft clavicle fractures from April 2016 to March 2020.

Intervention

Thirty-nine patients were treated with superior plating (Group SP), and the remaining 32 patients were treated with anteroinferior plating (Group AIP).

Main Outcome Measurements

Symptomatic implant removal rates after plate fixation for midshaft clavicle fractures.

Results

Symptomatic implant removal rates were significantly lower in Group AIP (28.1%) than in Group SP (53.8%) (P = 0.033). Multivariate analyses showed that symptomatic implant removal rates were significantly decreased by three independent factors, namely AIP (odds ratio [OR] = 0.323) (P = 0.037), greater age (45 years or older) (OR = 0.312) (P = 0.029), and high body mass index (≥25 kg/m²) (OR = 0.117) (P = 0.034).

Conclusions

AIP significantly and independently decreased the symptomatic implant removal rate. Among the three explanatory factors showing significant difference, plating technique is the only factor that can be altered by medical institutions. Therefore, we recommend this technique for displaced midshaft clavicle fractures to reduce a second surgery such as symptomatic implant removal.

Level of Evidence

Level 3, retrospective cohort study.

Anterior and superior plate positions in diaphyseal clavicle fractures produce similar patient outcomes

PURPOSE

While diaphyseal clavicle fractures can be treated with plate fixation on either the superior or anteroinferior aspect of the clavicle, the optimal plate position remains controversial. The purpose of this study was to determine if anteroinferior vs. superior plating for clavicle fracture fixation leads to better patient outcomes.

METHODS

A retrospective review of patients who sustained clavicle fractures (OTA/AO 15.2) treated with superior or anteroinferior plating at a tertiary Level I trauma center from 2015 to 2021 was performed. The clinical outcomes of clavicle fractures were compared between groups treated with an anterior versus a superior approach via Mann-Whitney U and Chi-squared tests as appropriate to evaluate for differences in outcomes between the two plate positions.

RESULTS

A total of 315 diaphyseal clavicle fractures were identified. One hundred and forty patients were excluded due to inadequate follow-up. Of the remaining 175 patients, 25 were treated with an anteroinferior approach (14%) and 150 were treated with a superior approach (86%). There were no differences in age, BMI, tobacco use, or substance use between the two groups (p > 0.05 for all). On univariate analysis, there was no difference in rate of union (p = 0.60), nerve injury (p = 0.60), infection (p = 1.0), implant-related irritation (p = 0.42), implant removal (p = 0.26), or revision (p = 1.0) based on approach. Contoured plates had an association with risk of nerve injury (p = 0.04).

CONCLUSION

There are no differences in union, nerve injury, infection, symptomatic implant, or revision rate between anteroinferior and superior clavicle approaches. Plate positioning during diaphyseal clavicle fracture fixation can reasonably be dictated based on surgeon preference and ideal reduction quality.

Are two plates better than one? A systematic review of dual plating for acute midshaft clavicle fractures

BACKGROUND

The rate of operative fixation of acute midshaft clavicle fractures has exponentially increased in recent years; however, the rate of reoperation for symptomatic hardware removal remains high and the optimal fixation strategy unknown. This systematic review aimed to summarize available evidence for dual plating of acute displaced midshaft clavicle fractures.

METHODS

EMBASE, MEDLINE, and PubMed searches identified clinical studies evaluating dual plate fixation of acute midshaft clavicle fractures. Pooled analysis was performed using a random-effects model in RevMan 5.3.

RESULTS

Eleven studies including 672 patients were included. Hardware removal occurred in 4.4% and 12.3% of patients undergoing dual and single plate fixation, respectively. Compared to single plating, dual plating had significantly lower odds of hardware removal (P = 0.001) with no difference in union rates. There were no significant differences in reoperation (excluding hardware removal), complications, and patient-reported outcomes between the two groups (P > 0.05).

CONCLUSIONS

This study suggests that dual plating of acute displaced midshaft clavicle fractures may lead to lower rates of reoperation for symptomatic hardware removal without compromising fracture healing. Ultimately, well-designed randomized trials are needed to further investigate the findings from this systematic review.

Risk Factors for Implant Removal After Surgical Fixation of Midshaft Clavicle Fractures

Midshaft clavicle fractures are common injuries that traditionally have been managed nonoperatively. However, recent literature has shown lower rates of nonunion and improved patient-reported outcomes with surgical management. The rate of implant removal after surgical fixation varies across the literature from 5% to 82%, depending on the method of fixation. We performed a retrospective review of all patients who underwent open reduction and internal fixation (ORIF) with plate-and-screw constructs for midshaft fractures of the clavicle at 2 level I trauma centers to determine the rate of implant removal and identify variables associated with implant removal. We collected all patient-, injury-, and treatment-specific factors as well as information on reoperation for removal of implants. Bivariate analysis and multivariable logistic regression analysis were used to assess whether explanatory factors were associated with removal of implants after ORIF for midshaft clavicle fractures. Of the 146 patients who were treated with ORIF for midshaft clavicle fractures with plate-and-screw constructs, 41 (28%) underwent removal of the implant. The median follow-up was 836 days (interquartile range, 457-1567 days). Variables associated with increased risk of implant removal included anterior plate position (odds ratio, 5.32; 95% CI, 2.01-14.1) and number of holes in the plate (odds ratio, 1.28; 95% CI, 1.00-1.63). These results question whether anterior plating results in less implant prominence and less subsequent removal of implants. [Orthopedics. 2022;45(4):e201-e206.].

Low profile dual plating for mid-shaft clavicle fractures: a meta-analysis and systematic review of observational studies

INTRODUCTION

Low profile dual plate fixation using two mini fragment plates (< 2.7 mm thickness) is a relatively new technique and alternative to single plating for treating midshaft clavicle fractures. To date, no meta-analysis has been performed comparing these two techniques. Therefore, a systematic review and meta-analysis of observational studies and randomized clinical trials was performed comparing single plating to low profile dual plating for midshaft clavicle fractures.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing both treatments. Effect estimates were pooled across studies using random effects models. The primary outcome is overall complication rate and re-intervention rate. Secondary outcomes include healing, operation duration and functional scores.

RESULTS

Low profile dual plating has favourable outcomes regarding overall complication rate (8.1% vs. 22.5%, OR 0.3, 95% CI 0.2-0.7, I² = 16%, p = 0.007) and re-intervention rate (6.1% vs. 16.1%, OR 0.3, 95% CI 0.1-0.9, I² = 25%, p = 0.02). The largest contributing factor behind these differences was the high incidence of implant related complaints in the single plating group (4.7% vs. 11.6%, OR 0.4, 95% CI 0.2-0.9, I² = 0%, p = 0.02). The use of low profile dual plating does not have a detrimental effect on healing with union being attained in 99% compared to 97.4% in the single plating group (OR 1.8, 95% CI 0.3-10.7, I = 0%, p = 0.5). Data on operating time and functional results is limited.

CONCLUSION

This meta-analysis shows that dual plating low profile plates for midshaft clavicle fractures is a safe procedure attaining the same union rates seen in patients treated with single plating. In addition, it seems to have a lower overall complication and re-intervention rate, mostly driven by the lower incidence of implant related complaints. Low profile dual plating, however, is a fairly new technique and should be further explored in respect to more differentiated endpoints to test whether these first findings are valid.

LEVEL OF EVIDENCE

III.

Does implant removal of superior clavicle plate osteosynthesis affect the functional outcome: a prospective trial

BACKGROUND

Elective implant removal (IR) accounts for up to 30% of all orthopaedic surgeries. While there is general acceptance about the need of implant removal for obvious reasons, such as infections or implant failure, little is known about the beneficial aspects in cases of minor reasons such as patients' wish for IR. Therefore, we initiated this study to define patients' benefit of elective implant removal following plate osteosynthesis of displaced clavicle fractures.

PATIENTS AND METHODS

Prospective evaluation of patients was conducted before implant removal and 6 weeks postoperative. Subjective and objective criteria included pain rating on a visual analogue scale (VAS) and active range of motion (ROM) pre- and 6 weeks postoperative. Functional scoring included Constant-Murley Score, DASH (Disabilities of Arm, Shoulder and Hand Score), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index).

RESULTS

37 patients were prospectively enrolled in this study and implant removal was performed after 16 ± 6.1 months. No re-fractures nor other complications were detected during routine follow up. Functional outcome increased through all scores (Constant score 73.3 ± 14.6 preoperative to 87.4 ± 12.0 postoperative (p = 0.000), MSQ 85.0 ± 7.3 preoperative to 91.8 ± 9.0 postoperative (p = 0.005), DASH Score 7.4 ± 8.2 preoperative to 5.7 ± 9.5 postoperative (p = 0.414), SPADI 93.4 ± 6.6 preoperative to 94.0 ± 10.1 postoperative (p = 0.734).

CONCLUSIONS

Discomfort during daily activities or performing sports as well as limited range of motion were the main reasons for patients' wish for implant removal. We found increased functional outcome parameters and decreased irritation after implant removal. Therefore we suggest implant removal in case of patients' wish and completed fracture consolidation.

TRIAL REGISTRATION

Trial registration no: NCT04343118, Retrospective registered: www.clinicaltrials.gov .

No difference in mid-term outcome after superior vs. anteroinferior plate position for displaced midshaft clavicle fractures

To compare outcomes, complications, revisions, and rates of implant removal of superior compared to anteroinferior plating in displaced midshaft clavicle fractures at mid-term follow-up. We retrospectively reviewed 79 patients who underwent operative treatment for displaced midshaft clavicle fractures (Group A: 28 patients with superior plating; Group B: 51 patients with anteroinferior plating) that were at least 2 years postoperatively. Adjusted Constant Score (aCS), Visual Analog Scale (VAS), and Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score were compared. Bone union, implant removal, complications and revision surgeries were assessed. Group A had a significantly higher aCS compared to group B (90, IQR: 85.0-91.0 vs. 91, IQR: 90.0-93.0; P = 0.037). No significant differences between groups were seen in VAS (P = 0.283) and QuickDASH (P = 0.384). Bone union was achieved in 76 patients (96.2%) with no significant differences between groups (Group A: 96.4% vs. Group B: 96.1%; P > 0.999). There were no significant differences in implant removal rates (Group A: 60.7% vs. Group B: 66.7%; P = 0.630), complications (Group A: 46.4% vs. Group B: 31.4%; P = 0.226) and revisions (Group A: 25% vs. Group B: 9.8%; P = 0.102). Superior and anteroinferior plating result in high bone union rates and good clinical outcomes with similar rates of plate removal.

Anteroinferior versus superior plating techniques for displaced midshaft clavicle fractures: A retrospective single centre cohort study from Northern Nigeria

BACKGROUND

Clavicle fractures are common injuries accounting for up to 5% of all fractures in adults. Most clavicle fractures heal well with nonoperative treatment, some however, require surgical intervention especially when they are displaced. While plating remains the most popular and most successful method of clavicle fixation; the optimal position of the plate is yet to be agreed upon.

PURPOSES

The purpose of this study was to compare the functional outcomes of displaced clavicle fractures fixed with superior and anteroinferior plating techniques.

PATIENTS AND METHODS

This retrospective cohort study of 69 patients (45 males and 24 females) was carried out between January 2014 and December 2018 at a government orthopaedic hospital in north-western part of Nigeria. The study involved all consecutive patients who sustained a displaced mid-shaft clavicle fracture and had open reduction and internal fixation (ORIF) with either superior plating (SP) or anterior-inferior plating (AIP) and were followed up for at least one year. Data analyzed include: age, sex, laterality, mode of injury, the time from initial injury to surgery, type of plate used, position of the plate, union rate, functional outcome and peri-operative complications.

RESULTS

Fourty-two patients had SP and twenty seven patients had AIP. Fourty one (97.6%) patients had fracture union in SP group while all the twenty seven patients (100%) in the AIP group had fracture union. The mean QuickDASH scores was 3.2 ± 4.6 and 3.6 ± 4.7 in AIP and SP groups respectively. There was no significant difference in the union rates and functional outcome between the two groups.

CONCLUSION

Both superior and anteroinferior plating techniques are safe and effective in the surgical management of displaced mid-clavicle fractures.

LEVEL OF EVIDENCE

Level 3, retrospective cohort study.

Prognostic factors and outcomes of secondary surgery after plate fixation for midshaft clavicle fracture: Comparison of traditional DCP and pre-contoured locking plate

OBJECTIVES

This study aimed to evaluate the prognostic factors of reoperation after plate fixation for midshaft clavicle fracture and compare outcomes of dynamic compression plates (DCP) and pre-contoured locking plates.

DESIGN

Retrospective comparative study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

We recruited 274 consecutive patients who underwent plate fixation for midshaft clavicle fracture from 2007 to 2017 and completed at least 1 year of follow-up.

INTERVENTION

235 patients underwent surgery with DCP, while 39 patients were treated with locking plate.

MAIN OUTCOME MEASUREMENTS

We reviewed the possible variables of secondary surgeries, and documented complications from the medical records. Patients with a DCP or locking plate were further divided for outcome comparisons.

RESULTS

150 (54.7%) patients underwent reoperation after the initial surgery, and plate removal represented the major etiology. On multivariate analysis, superficial wound infection and prominent implant were identified as significant risk factors for reoperation, while aging, locking plate usage, and higher body mass index (BMI) were protective factors (all P < 0.05). The locking plate featured a significantly decreased implant removal rate (7.7% vs. 60.9%, P < 0.05).

CONCLUSIONS

Patients with risk factors for superficial wound infection or a prominent implant tended to require a secondary operation after surgery for midshaft clavicle fracture, while aging, pre-contoured locking plate usage, and higher BMI decreased the risk. Compared with DCP, patients with locking plates tended to have better prognosis and significantly lower implant removal rates.

LEVEL OF EVIDENCE

Prognostic III.

Safety and efficacy of using 2.4/2.4 mm and 2.0/2.4 mm dual mini-fragment plate combinations for fixation of displaced diaphyseal clavicle fractures

PURPOSE

The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4 mm and 2.0/2.4 mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures.

METHODS

This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal.

RESULTS

All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal.

CONCLUSION

Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4 mm and 2.0/2.4 mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.

[Clavicular fractures : Diagnostics, management and treatment]

Clavicular fractures account for approximately 6% of bony injuries of the shoulder girdle. Patients suffering from this type of injury show 2 peaks (at the 2nd and 8th decades of life) where the majority occur in young active patients during recreational and sports activities. Besides an accurate patient history with a focus on the trauma mechanism, the clinical and radiological investigations are the cornerstones of the diagnostics. Slightly displaced fractures in a pediatric population as well as non-displaced fractures in adults can be treated conservatively. In cases of shortening and/or displacement and high functional demands, operative treatment of clavicular fractures, stable fixation and the possibility of early mobilization and therapy can be achieved; however, the indications for the procedure also depend on other factors. Surgical stabilization can substantially reduce the danger of non-union, which is why it is becoming more important.

Clavicle fractures in adults; current concepts

BACKGROUND

For decades, clavicle fractures have been treated conservatively. In the last 20 years, however, non-union rates after conservative treatment appear higher than previously reported and more evidence regarding operative treatment has become available. This has led to a paradigm shift towards an increase in operative treatment. The aim of this review is to present the current concepts and available evidence regarding clavicle fracture treatment.

METHODS

Conservative and operative treatment options together with their indications for medial, shaft and lateral clavicle fractures are discussed. For all three anatomical locations, a treatment algorithm is proposed.

CONCLUSION

In general, non-displaced fractures are treated conservatively. Operative treatment has to be discussed with patients with displaced clavicle fractures, especially in the young and active patient.

Why off-the-shelf clavicle plates rarely fit: anatomic analysis of the clavicle through statistical shape modeling

BACKGROUND

The clavicle presents a large variability in its characterizing sigmoid shape. Prominent and nonproperly fitting fixation plates (FP) cause soft tissue irritation and lead to hardware removal. It is therefore key in FP design to account for shape variations. Statistical shape models (SSMs) have been built to analyze a cluster of complex shapes. The goal of this study was to describe the anatomic variation of the clavicle using SSMs.

METHODS

Two different SSMs of the clavicle were created, and their modes of variation were described. One model contained 120 left male and female clavicles. The other model consisted of 76 left and corresponding right clavicles, 41 originating from men and 35 from women.

RESULTS

The model of 120 left clavicles showed that 10 modes of variation are necessary to explain 95% of the variation. The most important modes of variation are the clavicle length, inferior-superior bow, and medial and lateral curvature. Statistically significant differences between male and female clavicles were seen in length, sigmoid shape, and medial curvature. Comparison in men between left and right revealed significant differences in length and medial curvature. For women, a statistically significant difference between left and right was only seen in the length.

CONCLUSIONS

Although the operative treatment of displaced midshaft clavicular fractures has clear benefits, the variable anatomy of the clavicle often makes it challenging for the surgeon to make the plate fit adequately. Based on the identified variability in the clavicle's anatomy, it seems unlikely that a clavicle plating system can fit the entire population.

Five-Year Follow-up Results of a Randomized Controlled Study Comparing Intramedullary Nailing with Plate Fixation of Completely Displaced Midshaft Fractures of the Clavicle in Adults

Background:

Surgical management of completely displaced midshaft fractures of the clavicle is becoming more frequent, although long-term follow-up with Level-I evidence is scarce. Plate fixation (PF) of comminuted fractures provides faster functional recovery than elastic stable intramedullary nailing (ESIN). The 12-month follow-up of this randomized controlled trial, published previously, found no clinical differences at that time on the group level, but subtle differences on the subgroup level indicated that the results after closed ESIN were better than those after open ESIN. The primary aim of the study reported here was to compare the long-term clinical outcomes and sequelae after open reduction with those after closed reduction and to help surgeons develop a treatment strategy of either PF or ESIN for selected patients.

Methods:

At a median follow-up of 66 months (range, 49 to 89 months), the 123 patients in the original study were invited to an online secure survey. We used the survey results to compare the PF and ESIN treatment arms and to perform predetermined subgroup analyses of closed compared with open ESIN in relation to Disabilities of the Arm, Shoulder and Hand (DASH) score, pain assessment, and implant removal.

Results:

The questionnaire was completed by 114 (93%) of the 123 patients. There were no differences between the 2 treatment arms with regard to the DASH score (ESIN, 3.1 ± 7.0 and PF, 3.7 ± 7.5; p = 0.9). The 27 patients who had been treated with closed ESIN had a significantly superior DASH score compared with the 27 patients who had been treated with open ESIN (closed, 0.7 ± 1.4 and open, 5.2 ± 8.9; p = 0.015) and compared with the patients who had been treated with PF (closed ESIN, 0.7 ± 1.4 and PF, 3.9 ± 7.5; p = 0.002). Patients who had been treated with closed ESIN also reported fewer sequelae than patients who had been treated with open ESIN or PF.

Conclusions:

The results of this study, combined with those of our prior 1-year follow-up of the same patients, indicate that it seems to be advantageous to perform closed ESIN. The long-term results after PF were similar to those after open ESIN, but PF resulted in faster functional recovery and fewer patients needing to have the implant removed. Therefore, if open reduction is necessary for a comminuted fracture, it seems that the advantages of the minimally invasive ESIN procedure are lost, and the surgeon should consider conversion to PF.

Level of Evidence:

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clavicula fractures: considerations when plating

The preferred treatment of clavicula midshaft fractures in adults has gone from being very conservative into surgery being frequently recommended. However, based on recent meta-analysis favorable outcome with internal fixation is not as consistent as previously reported. Probably due to a combination of indications for surgery becoming too wide and surgery being performed by a wider group of surgeons. When using plating for clavicula fractures there are several considerations to consider to improve outcome while reducing the risk for complications. Traditionally a horizontal approach along the clavicula is used as it provides good exposure. However, this incision is associated with a high risk for permanent anterior chest wall numbness that might be very disturbing for patients. A vertical incision can instead be used. Plates are traditionally placed in a superior position. An alternative can be an anterior-inferior position that allows better soft tissue coverage, less risk for hardware protrusion, longer screws can be used and the risk for damaging the underlying neurovascular bundle is reduced. Angle-stable screw-plate systems has not in a convincing way shown any benefit in clavicula fractures. In part because most patients have good bone quality where conventional screws will be sufficient.

What is the hardware removal rate after anteroinferior plating of the clavicle? A retrospective cohort study

BACKGROUND

Plate position in the operative treatment of displaced midshaft clavicle fractures or nonunions is most often on the superior side. However, superior clavicular plating often results in complaints of plate prominence and local soft tissue irritation, necessitating hardware removal. We have used anteroinferior placement of the plate in the hope of increasing biomechanical stability and fixation and also of lowering complaints of plate prominence and soft tissue irritation. In this report, we set out to study the percentage of hardware removal in our group of patients treated with anteroinferior plating of the clavicle after long-term follow-up.

METHODS

In this retrospective review, we evaluated all patients who were surgically treated with anteroinferior plating for midshaft clavicle fracture, delayed union, or nonunion by the senior author between February 2003 and July 2015. Patients required a minimum age of 16 years at time of surgery and a follow-up of >12 months. Patients with malunion, plating on the superior aspect, or double plating were excluded.

RESULTS

The medical records of 53 patients (54 fractures) were reviewed after a mean follow-up duration of 6.4 years (range, 1.1-13.1). The mean age at follow-up was 47.8 years (range, 20.4-80.7). All fractures and nonunions healed. In only 3 cases (5.6%), hardware removal was requested by the patient because of plate prominence.

CONCLUSIONS

Anteroinferior plating of midshaft clavicle fractures, delayed unions, and nonunions resulted in low hardware removal rates in our cohort.

Functional recovery following early mobilization after middle third clavicle osteosynthesis for acute fractures or nonunion: A case-control study

BACKGROUND

Good outcomes have been reported after surgical treatment for acute or nonunion of displaced midshaft clavicle fractures. However, the postoperative rehabilitation and timeline for a complete functional recovery are poorly documented. The purpose of the current study was to evaluate the efficacy of an immediate motion protocol following plate fixation of a midshaft clavicle fracture and to compare functional recovery between acute and nonunion cases.

METHODS

Between October 2011 and July 2015, all patients above the age of 18, having either an acute or a nonunion of the midshaft clavicle fracture, were considered as potentially eligible for inclusion in this prospective case-control study. Postoperatively, no immobilization was recommended and patients were to undergo rehabilitation protocol consisting of hourly stretching.

RESULTS

Forty-two patients were included (31 with acute and 11 with delayed fixation) at a mean follow-up of 33months (range, 12 to 78months). Surgical complications consisted of one transient frozen shoulder, one delayed union, and two superficial infections. All patients returned to work, retrieved full shoulder range of motion (ROM), and returned to heavy sports and activities. Function returned faster in the acute group compared to the nonunion group based on the SANE score at 2weeks (73±21 vs. 45±26 respectively, P=0.01), SANE score at 6weeks (89±15 vs. 66±23 respectively, P=0.01), SANE score at 3months (96±10 vs. 85±14 respectively, P=0.03), and based on return of full ROM (17±25 vs. 44±31 days respectively, P=0.01). A trend was observed for nonunion cases needing more time to return to work and sports activities.

CONCLUSION

Functional outcome is excellent following the treatment of both acute and non-united clavicle fractures, but recovery occurs earlier following acute treatment. An early mobilization rehab protocol can be safely recommended for both types of conditions and may result in substantial healthcare cost-savings, without increasing complication rate and decreasing patient satisfaction.

LEVEL OF EVIDENCE

Level III; case-control study; treatment study.

Anterior-Inferior Plating Results in Fewer Secondary Interventions Compared to Superior Plating for Acute Displaced Midshaft Clavicle Fractures

OBJECTIVES

To determine whether a difference in plate position for fixation of acute, displaced, midshaft clavicle fractures would affect the rate of secondary intervention.

DESIGN

Retrospective Comparative Study.

SETTING

Two academic Level 1 Regional Trauma Centers.

PATIENTS

Five hundred ten patients treated surgically for an acutely displaced midshaft clavicle fracture between 2000 and 2013 were identified and reviewed retrospectively at a minimum of 24 months follow-up (F/U). Fractures were divided into 2 cohorts, according to plate position: Anterior-Inferior (AI) or Superior (S). Exclusion criteria included age <16 years, incomplete data records, and loss to F/U. Group analysis included demographics (age, sex, body mass index), fracture characteristics (mechanism of injury, open or closed), hand dominance, ipsilateral injuries, time between injury to surgery, time to radiographic union, length of F/U, and frequency of secondary procedures.

INTERVENTION

Patients were treated either with AI or S clavicle plating at the treating surgeon's discretion.

MAIN OUTCOME MEASURES

Rate and reason for secondary intervention.

STATISTICAL ANALYSIS

Fisher exact test, t test. and odds ratio were used for statistical analysis.

RESULTS

Final analysis included 252 fractures/251 patients. One hundred eighteen (47%) were in group AI; 134 (53%) were in group S. No differences in demographics, fracture characteristics, time to surgery, time to union, or length of F/U existed between groups. Seven patients/7 fractures (5.9%) in Group AI underwent a secondary surgery whereas 30 patients/30 fractures (22.3%) in group S required a secondary surgery. An additional intervention secondary to superior plate placement was highly statistically significant (P < 0.001). Furthermore, because 80% of these subsequent interventions were a result of plate irritation with patient discomfort, the odds ratio for a second procedure was 5 times greater in those fractures treated with a superior plate.

CONCLUSIONS

This comparative analysis indicates that AI plating of midshaft clavicle fractures seems to lessen clinical irritation and results in significantly fewer secondary interventions. Considering patient satisfaction and a reduced financial burden to the health care system, we recommend routine AI plate application when open reduction internal fixation of the clavicle is indicated.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Midshaft Fractures of the Clavicle: A Meta-analysis Comparing Surgical Fixation Using Anteroinferior Plating Versus Superior Plating

OBJECTIVE

To compare the outcomes of clavicle fracture fixation using anteroinferior versus superior plate placement.

METHODS

We performed a meta-analysis of studies that have reported on outcomes after superior or anteroinferior plate fixation for acute midshaft clavicle fractures (Orthopaedic Trauma Association 15-B). A computerized literature search in the Pubmed, Scopus, and Cochrane Library databases was used to identify relevant articles. Only full text articles without language restrictions were evaluated. The inclusion criteria consisted of: (1) fracture of the midshaft clavicle; (2) surgery for acute fractures (within 1 month of the fracture); (3) adult patients (16 years of age and older); and (4) open reduction and internal fixation with plate application in either the anteroinferior or superior position. Studies were excluded if they did not specify plate location, evaluated multitrauma patients, investigated minimally invasive procedures, or studied operations for revision, nonunion, malunion, or infection. The primary measured outcomes were symptomatic hardware (implant prominence or irritation) and surgery for implant removal. The secondary outcomes were time to union, fracture union, nonunion, malunion, Disabilies of the Arm, Shoulder and Hand score, Constant score, and implant failure. Frequencies and proportions of cases were recorded for binary outcomes, whereas mean and standard deviations were recorded for continuous outcomes. Other summary statistics provided were used to impute mean and standard deviations under the assumption of normality when these were not reported. Continuous outcomes were compared between groups using linear mixed effects models, whereas binary outcomes were compared using mixed effects logistic regression models, including fixed group effects and random study effects. P-values less than 0.05 were considered statistically significant. All analyses were performed using SAS v. 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

A total of 1428 articles were identified among the 3 databases, of which 897 remained after removing duplicates. From that pool, 57 relevant studies were evaluated. Articles were excluded because of an inability to specify plate location (6), a subject pool not exclusively consisting of acute fractures (4) or midshaft fractures (2), a minimally invasive surgical approach (6), use of nonstandard plates (1), poor reporting of functional outcomes (2), and a duplicate group of patients (2). This left 34 articles to be used in the meta-analysis. Of these, 8 studies reported on patients with anteroinferior plating (N = 390) and 27 studies reported on patients with superior plating (N = 1104). No significant differences were found with respect to the functional shoulder scores (Disabilies of the Arm, Shoulder and Hand and Constant) between the 2 groups. There was no significant difference between each group for the probability of having a union (P = 0.41), malunion (P = 0.28), nonunion (0.29), or implant failure (P = 0.39). Patients in the superior plating group had a significantly higher probability of suffering from symptomatic hardware (0.17) as compared to patients in the anteroinferior plating group (0.08), (P = 0.005). In addition, the superior plating group had a significantly higher rate of surgery for implant removal (0.11 vs. 0.05), (P = 0.008).

CONCLUSIONS

The findings of this investigation demonstrate that plating along the superior and anteroinferior aspects of the clavicle lead to similar operative outcomes with respect to union, nonunion, malunion, and implant failure, as well as similar functional outcomes scores. Plates applied to the superior aspect of the clavicle are associated with higher rates of symptomatic hardware and more frequent implant removal.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior inferior plating versus superior plating for clavicle fracture: a meta-analysis

Background

The position of plate fixation for clavicle fracture remains controversial. Our objective was to perform a comprehensive review of the literature and quantify the surgical parameters and clinical indexes between the anterior inferior plating and superior plating for clavicle fracture.

Methods

PubMed, EMBASE, and the Cochrane Library were searched for randomized and non-randomized studies that compared the anterior inferior plating with the superior plating for clavicle fracture. The relative risk or standardized mean difference with 95% confidence interval was calculated using either a fixed- or random-effects model.

Results

Four randomized controlled trials and eight observational studies were identified to compare the surgical parameters and clinical indexes. For the surgical parameters, the anterior inferior plating group was better than the superior plating group in operation time and blood loss (P < 0.05). Furthermore, in terms of clinical indexes, the anterior inferior plating was superior to the superior plating in reducing the union time, and the two kinds of plate fixation methods were comparable in constant score, and the rate of infection, nonunion, and complications (P > 0.05).

Conclusions

Based on the current evidence, the anterior inferior plating may reduce the blood loss, the operation and union time, but no differences were observed in constant score, and the rate of infection, nonunion, and complications between the two groups. Given that some of the studies have low quality, more randomized controlled trails with high quality should be conduct to further verify the findings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-017-1517-1) contains supplementary material, which is available to authorized users.